The URL can be used to link to this page

Home My WebLink AboutZODIAK MANOR ALASKA BLK 5 LT 28 I:'lF:F,?fd :[ "1 F,II3 :ii I]11]:1 I:;l{~!i i' I::()l:;~ I:::t I:::'l,i']',,,'l::lllil I,Ii]ZI I Iii]ti:;] ;iil]~tl]!]l I::Ii]I!Z'i I:::'Ol:;?. I:::1 I:::'t..ti?,l. ]t](]: I,.lli]LI I,Ilill I I.(Xii:i; I:11:;;iii I:;i:iilil;!i.iil]l;?.li]lZ) F:II'-,ii)HI.ti!!;t' i?,IE] I;?.li'i'l. IF;-'.t'-,ltli][':, '1'O Il'liE Ii:,lii]l:::'l:::ll:;~:l'Hl]NI O1::: 'lllliZ t,iliii.i. O;;)tqi:::'i lil tON. 'i;t:::'t](il.]F](.,l:::ll )Z()N:; I::'I?',tD (]];(iZII",Ii;II:;~I.IIZ;I ]ll]ll",l i?[l::l(]il:;]q::;ll'l:!i; I:::tI:;irE I:::1"?1:::t]]1 I::1I!~1 I] ii] I",P. ii; I I::11. I !::1i ]Z F:i.It:;]:IIt !~'-,' iiti HI Ii",t ]i (ii: i[ l:::q:::tl iIT"~.' (ill::: 2; ) Id]Il i] N: i; l l::ll I IIii:i :ii:;",':i;liii'l itii'-,I I::~(iZ;(i:Oi:;41)l::il'-,llil;;i.. I'.l]]'fll 'l'lll~i LEGAL DESCRIPTION GREA_ ,:R ANCI-IORAGE AREA BO[", .JGH APPLICATION ANI') PERMIT INSTALLATION OF: SEPTIC 'rANK SEEPAGE PIT , DRAIN FIELD , OTHER SOIL TEST RESULTS ................... NOTE~ TI'liS PERMIT I~ NOT VALID WITHOUT SOIL TE$'f COMPLETION DATE ANTICIPATED SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE ____ TYPE WELL TO SEPTIC TANK DRAIN FIELD- GRAVEL BACEFILL DIAGRAM or; SYSTEM I CERTIFY THAT I AM FAMILIAR WITh THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOfiOUGH ORO[NANCE NO. 28-68 AND THAT THE ABOVE MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) < ' A- klc /-% K (b) Property owner ~5'~ ~ec.~,** /-,ee,,,c¢_ T~ ephone. (home) Mailing Address ,,~J~L(%/-i (c) Lending Institution i~,L//~- Mai,,ng Address (d) Real Estate Company and Agent Address ki /A Business Telephone Telephone ~'~././~. (e) Mail the HAA to the following address: (or check here'/~if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family~.._ Number of bedrooms 4 3. WATER SUPPLY Individual Well'i~ Community [] Public [] Note: If community well system, must have written confirmation from the State.Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL Publicx' Community [] Holding Tank [] On-site Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is sere, functional end adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Date 6. DHHS APPROVAL Approved for /?/ __bedrooms by Approved ~ Disapproved Terms of Conditional Approval ,~. ~',-/~~'/Date Conditional The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements, Employees of DH HS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev 7/88)Back Page 2 of 2 A. WFLL DATA RECEI Well Classification _ /~/~l. Well Log Pre~t (Y/N) _ ? Date Completed Total Depth ,~J-! ?Oased to m~/'~'-( Depth of Grouting Static Water Level _ (~o~'' · Casing Height Above Ground /r~ Electrical Wiring Jn Conduit (Y/N). / SEPARATION DISTANOES FROM WELL: 'I-o Septic/Holding Tank on Lot ~, To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line -7_~-~ To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample 'rest Results MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (NAA) ~ UlE~OKIJST ,-.F,,E.B~,.U,,.ARY 1984 ~ NVIRoNMENrAL34~ :744'i · ~[aDIVISION !' ¢:/-~ , Legal Description: J~o'~- ~.~ If A, B, C, D.E.C. Approved (Y/N) Yield LZ~~' ~-D'~ Pump Set At _LJ.kl ~' .4J~c,.~ N Sanitary Seal on Casing (Y/N) _V Depression Around Wellhead (Y/N) ~ ;On Adjoining Lots /~//el: __ ; On Adjoining L. ots To Nearest Public Sewer Cleanout/Manhole ;Date B. SE~C/HOLDIN G 'rANK DA'fA Date In'~led _ Size _ //N~oo~-of Compartments Standpipe~N) ____ Air-tight Caps (Y/N) ______ Foundation Cleanout (Y/N) Depression ovehN~ank (Y/N) __ Date Last Pumped __ Pumping/Maintena%Contact on File (Y/N) ..... ; for ____ __ Holding Tank I-r~gh-Wat~,~arm (Y/N) _____ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCEST-~M SEPTIC/HOLDING TANK: -Fo Water-Supply Well ~ To Building Foundation ~foO ~V o~MYaiLl~;ervice Lin e _ ~,. To Disposal Field Mai--or To Stream, Pond, Lake or Drainage Cour~e~ Comments 72-026 (Rev 7/88) From Page 1 of 2 C. ABSORP~I~FIELD DATA Soils Rating in~sorption Strata Type of System Design Date Installed ~ Length of Field Width of Field _ %,, Depth of Field Gravel Bed Thickness Square Feet of Absortion A?e~_ Statndpipes Present (Y/N) Depression over Field (Y/N) % Date of Last Adequacy Test Results of Last Adequacy Test %~ FROMA~,~ FIELD: SEPARATION DISTANCE PTION To Water-Supply Well To Property Line To Building Foundation ~ To Existing or Abandoned System on Lot %,~On Adjoining Lots To Water Main/Service Line ~ To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course ~ To Driveway, Parking Area, or Vehicle Storage Area _ % Comments ~ Date I n s t ~,J,,~ Size in Gallo~ "Pump On" Leveh,~ W~gh Water Alarm L~,~at Tested for ~ Meets MOA Electrical Code'~Y/N) Comments ~ Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. ** Check Perm/~d Bed ro/Rating Against HAA Request** I certify that/I/R,~av,e chec.~cd;'~'erified, or conformed to all MOA and H,I~i inspection. / /// /// Signed ~/~ MOA No. ~ R celp No. / Date of Payment Amount: $ on the date of this Engineer's Seal 72-026 {Rev 7/88) Back Receipt No Waiver Fee: $ Date of Payment Page 2 of 2 Clock Tine LOCAl IO;I Of WElL (Legal {)escripLioa): DATE [/RILLIIIG COMPLETED: STATIC t-lATER LEVEL (lop of Casing): I]~l~-psed -1Tmi SinceI pumping'Star~ed/ SEopped, ; 80' I s I to I 15 I 2o I 3s t 40 I . -45 I so I ss I 6o ([ hour)j -'. 90 j ~-1~0 (Z hours)l I FT SCflEEH: / F T Pumping Ra~e, I 0 J Start tSO (3 hours)F TELEPHONE (907) 562.2343 5633 B Street ~ Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED E~Y WATER SUPPLIER ~---PI~IVATE WATER SYSTEM Name Phone No. City q S~ate Mo. Day Year Zip Code SAMPLE TYPE: JZ"Routine ~'[] Check Sample (for routine sample with lab ref. no. _) [] Special Purpose [] Treated Water [] Untreated Water SAMPLE ~ Time NO. LOCATION Collected TO BE COMPLETED BY LABORATORY ls shows this Water SAMPLE to be: Is factory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to Indicate reliable results. Please send new sample via special delivery mail. Date Received ~_) - ~O Time Received 07~0 Analytical Method: Membrane Filter * No. of colonies/100 mi. Collected Lab Ref. No. Result* Analyst I 7: I I READ INSTRUC'rlONS BEFORE COLLECTING SAMPLE Membrane Filter:. Direct Count C) Verification: LTB Final Membrane EIIt~'~,,ults ~,¢~ C~ TNTC = Too Numberous To Count OB = Other Bacteria BGB [)ate ___'~ - ~--- ~..~ Time; _ ( ~ C-J~'~"~ a.m. ~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. / ,/Z~.~ FEDERAL TAX ID # 92.0040440 Cll(,nt Acct : APPLIC FILLS OUT UPPER HAl. ONLY lPhone Buyer Address Zip Code Phone Lending Institution Address Zip Code Address Zip Code Type of Residence ingle Family ~).~,~ ,..~.~;,/- Alq'ACH WELL LOG. A well log is required for all wells drilled since June 1975. E] Community · f For wells drilled prior to that date, give well depth (attach log if available). [] Public Utility Sewer Disposal Hd ividual Year individual Installed: __._ Public Utility When Connected to Public Utility: olding Tank NOTE: THE INSPECTION I:EE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Lr~L x~ /~ g Date Date Date Date~` \ ~- ~, Plaid Notes: ~ MU~I~IPALI~ OF ANCHORAGE ~ D~PT. O~ HEALTH 8< RECEIVED. ~) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE ~ ~~ Weg to Tank Septic T~[ Size CHEMICAL & Gl. LOGICAL LABORATORIES ~. F ALASKA, INC. TELEPHONE !,907)-279,4014 ANCHORAGE INDUSTRIAL CENTER 274-3364 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE! COMPLETED BY WATER SUPPLIFR WATER SYSTEM: Water System Name i.D. NO. Phone No. Mailing Address State MO, Day Year Zip Code SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab r~f, no. ~ [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. LOCAI'IOH Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: [] Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received Time Received Analytical Method: [] Fermentation Tube [] Membrane Filter Lab Ref. No. L Result* Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 0g-1220 (b} Rev. 197g BACTERIOLOGICAL WATER ANALYSIS RECORD =relumptlvo 1omi 1Omi 1Omi 1omi 1omi 1,0mi O.lml . Collforrn/lOOml DEPARTME, 825 ~UNICIPALIFY OF ANCHORAGE HEALTH AND ENVIRONMEN] Street, Anchorage, Alaska 264-4720 ROTECTION '99501 Date Received: March 21, ].978 Time 3::L5 p.m. #2: Time ~3: Date 3-22-78 Thursday Date Pratt Insp Insp Time Date Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES Lending Institution Request: Mailing Address: Phone: Property Owner: william J. Stephens Mailing Address: Box 4-1091 99509 Phone: 349-1433 3. Legal Description: 4: Single Family Residence: (~ Multiple Family Residence: ( ) 5. Well System: Individual Well Permit = Construction Lot 28 Block 5 Zodiak Manor Subdivision Number of Bedrooms: Four Number of Bedrooms: ( ~ Community/Public System ( Depth of Well 140' Well Log on File Bacterial Analysms Permit Septic Tank Size Absorption Area Sewage Disposal System: On-site System ( ) Public Utility Installed Insl:~ller Manufacgurer Soils Rate Materzal ( x~ 7. Distances: Well to Septic Tank ~o Absorption Area te Sewer Line Neares~ Lot line Absorption Area to Neares~ Lot Line Page Two Department of Health and Environmental Protection Request for Approval of Individual Sewez and Water Facilities Legal Description: Lot 28 Block 5 Zodiak Manor Subdivision Comments: Disapproved: Letter Attached: ( Date: Date: Department Worksheet: CO ~UNICIPALITY OF ANCHORAGE Department of Itealth and Environment~% Protection ~ 825 L Street, Anchorage, Alaska 99501 2 6 4 - 4 7 2 0 '*~quest for Approval of Individual Sewer and Water Pacil'ities Property Owner: Mailing Address: 21 Name of Buyer: __, Mailing Address: Phone: ,J[¢/Z~ -__/~_~ Lending Instztutzo · Mailing Address: Phone: o 6 o Realtor/Agent: Mailing Address: Legal Description: Street Location: Single Family Residence: (~/ Number of Bedrooms: Mu].tiple Family Residence: ( ) Number of Bedrooms: Phone: 7 o Water Supply:_ *Individual Well (J~ If Individual Well, well depth =/~/z~ If Community System, name of system Sewage Disposal System: *~On-site System Iff On-site System, date of installation: Public/Conm~unity System ( ) ( ) Public System *NOTE: A well log is required on ALL wells drilled since 6/75. ** If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request before processing. can be initiated. 3/77 06-1220(a) Rev. 1973 DATE ALAS. ARTMENT OF HEALTH AND SOCIAL SE[ DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMi-PUBLIC BACTERIOLOGICAL WATER ANALYSIS Lab No. OFFICE SEMI-PUBLIC [] CHLORINE RESIDUAL 'PM REPORT RESULTS TO NAME ADDRESS CITY ADDRESS OF SOURCE ZIP CODE COMPLETE This 'SECTION ONLY IF WATE~ IS AN, INDIV],D. UAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED : ) : "~'~ TIME COLLECTED _ ~ Well- [~ Dug [] Driven [] Drilled ~ Bored SOURCE: [] Spring [] Cistern ~ Olher__ Dug Well or Cistern Construction: Wails -- Wood GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No C) Of Well [] Other . PURPOSE OF EXAMINATION: illness Suspecled? [] Yes READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE Yes ~ No S[gnafure Analysis shows this Water SAMPLE to be: [~] Satisfactory [] Unsatisfactory [] QuesHonable [] Sample too long in transit; sample should not be over 48 hours old at examination to ind[cale reliable results. Please send new sampJe. [] Bottle brohen in transit, please send new sample. SANITARIAN'S REMARKS 06-1220 (bi BACTERIOLOGICAL WATER ANALYSIS RECORD ,' Lactose Brolh 10cc IOcc 10cc 10c¢ 10£c 1.0cc 1.0cc 2d Hours 48 Hours Reported by - ~% A~,~,oTT 12 153 152 ~®~ 12 162 Hidden Lake Area Reference Map-P12